CLINICAL PATHOLOGY WORKSHEET

1. Accession #____________________________________ Common Name:________________________________ ID #__________________________________________ Collection Information Type of Restraint: Phys. Chemical Behav. Date of Collection: Day______ Mo_______Yr______ Time of Collection:________:_________ Health Status: Normal Abnormal Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours Activity: very low low elev. highly elev. variable indeterminate Actual Weight:__________ kg lb gm Collection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other Person Collecting Sample:_____ ______ ______ Hematology Tests and Results WBC:__________ x 10(3)/mm(3) RBC:___________ x 10(6)/mm(3) HGB:___________gm/dl HCT:___________% Reticulocytes:___________% Segmented Neutrophils:___________%________/mm(3) Neutrophilic Bands:___________%___________/mm(3) Lymphocytes:______________%_____________/mm(3) Monocytes:________________%_____________/mm(3) Eosinophils:________________%_____________/mm(3) Basophils:_______________%_______________/mm(3) Metamyelocytes:_____________%___________/mm(3) Nucleated RBCs:_______________________/100 WBC Azurophils:__________________%___________/mm(3) Coarse Eos Granulocytes:__________%_______/mm(3) Fine Eos Granulocytes:___________%_________/mm(3) Platelet Estimate:___________________ Granulated Thrombocytes:________%________/mm(3) Thrombocyte Estimate:__________________ Erythrocyte Sed Rate:________________/mm/hr Total Protein (refractometer):______________mg/dl CLINICAL PATHOLOGY WORKSHEET Hematology Analysis Information Date of Analysis: Day______ Mo______Yr_______ Time of Analysis:__________:___________ Time of Blood Smear:_________:_________ Laboratory:_______________________________ Automated Analysis: Yes No Person Performing:______ _______ _______ Additive EDTA Citrate Heparin Other___________ Oxalate Not recorded Anticoagulant Form: Dry Liquid Sample Clotted: Yes No Diff Quik Wrights Giemsa May-Grumwald Sample Appearance: Hemolytic Lipemic Sample too small: Yes No Initial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours >48 hours Condition: not deteriorated deteriorated Manual Differential: Yes No Morphology Occ. Mild Mod Marked 1+ 2+ 3+ 4+ Anisocytosis Poikilocytosis Polychromoasia Howell-Jolly Bodies Target Cells Basophilic Stippling Hypochromis Rouleaux Formation RBC: Normal WBC: Normal WBC is estimate Morphology Comments:_________________________________ ______________________________________________________ ______________________________________________________ Reason for tests/Tests Requested:

2. Collection Information Type of Restraint: Phys. Chemical Behav. Date of Collection: Day______ Mo_______Yr______ Time of Collection:________:_________ Health Status: Normal Abnormal Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours Activity: very low low elev. highly elev. variable indeterminate Actual Weight:__________ kg lb gm Collection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other Person Collecting Sample:_____ ______ ______ Accession #______________________________ Common Name:_____________________________ ID #:____________________________________ Chemistry Tests and Results Glucsose:________________________mg/dl BUN:___________________________mgdl Creatinine:______________________mg/dl Uric Acid:_______________________mg/dl Calcium:________________________mg/dl Phosphorus:_____________________mg/dl Sodium:_________________________meq/dl Potassium:_______________________meq/dl Chloride:________________________meq/dl CO2:____________________________MMOL/L Alk Phos:________________________IU/L AST (SGOT):_____________________IU/L ALT (SGPT):_____________________IU/L Cholestrol:_______________________mg/dl Total Protein (C):__________________gm/dl Total Protein (R):__________________gm/dl Total Bilirubin:____________________mg/dl GGT:____________________________IU/L Amylase:_________________________IU/L BUN/Creatinine Ratio:________________mg/dl Albumin:__________________________g/dl CK:______________________________U/L Globulin:__________________________g/L Alb/Glob Rato:____________________ CLINICAL PATHOLOGY WORKSHEET Chemistry Analysis Information Date of Analysis: Day______ Mo______Yr_______ Time of Analysis:__________:___________ Laboratory:_______________________________ Automated Analysis: Yes No Person Performing:______ _______ _______ Type of Sample: Serum Plasma Whole Blood Anticoagulant: EDTA Citrate Heparin Other___________ Oxalate Not recorded Anticoagulant Form: Dry Liquid Sample Quality: Hemolytic Lipemia Sample too small: Yes No Initial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours >48 hours Condition: not deteriorated deteriorated Extra Chemistry Tests:__________________________________ ______________________________________________________ ____________________________________________________________________________________________________________ Comments:____________________________________________ ______________________________________________________ ______________________________________________________ ____________________________________________________________________________________________________________